| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
66 |
51 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
214 |
124 |
$14K |
| D1110 |
Prophylaxis - adult |
118 |
118 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
189 |
189 |
$9K |
| D4342 |
|
161 |
72 |
$7K |
| D4341 |
|
83 |
35 |
$6K |
| D0350 |
|
339 |
243 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
265 |
265 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
39 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
103 |
$626.10 |
| D9430 |
|
14 |
14 |
$448.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$201.60 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$172.00 |